NUR 2356 Multidimensional Care I
Exam 2
Question:
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? Crackles, Rhonchi, Stridor, Wheezes.
Answer:
Wheezes
Question:
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? Mix the three medications together prior to administering, Dilute each medication with 10 mL of tap water, Maintain the head of the bed in a flat position for 30 min following medication administration, Flush the NG feeding tube with 30 mL of water immediately following medication administration.
Answer:
Flush the NG feeding tube with 30 mL of water immediately following medication administration
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Question:
A nurse is caring for client who has a single lumen central venous catheter.Which of the following actions should the nurse take when accessing the catheter? Use a 10-mL syringe to flush the catheter, Flush the lumen with sterile water after each use, Use clean technique when accessing the catheter, Apply firm pressure to the syringe plunger when flushing the lumen.
Answer:
Use a 10-mL syringe to flush the catheter
Question:
A nurse should teach which of the following clients requiring crutches about how to use a three-point gait? A client who is able to bear full weight on both lower extremities, A client who has bilateral leg braces due to paralysis of the lower extremities, A client who has a right femur fracture with no weight bearing on the affected leg, A client who has bilateral knee replacements with partial weight bearing on both legs.
Answer:
A client who has a right femur fracture with no weight bearing on the affected leg
Question:
A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? Insert the needle into the needless port at a 60° angle, Withdraw 3 to 5 mL of urine from the port, Wipe the area of needleless port with sterile water. 2 / 4
Answer:
Withdraw 3 to 5 mL of urine from the port.
Question:
A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? Metabolic acidosis, Metabolic alkalosis, Respiratory acidosis.
Answer:
Metabolic alkalosis
Question:
pH:
PaCO2:
HCO3:
HCO3= PaCO2=
Answer:
pH: 7.35 - 7.45
PaCO2: 45 - 35
HCO3: 22 - 26
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HCO3= Metabolic PaCO2= Respiratoy
Question:
A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration? A client who has a chest tube following a fall from a ladder, A client who had a hemi-colectomy and placement of a colostomy, A client receiving continuous enteral feeding through NG tube, A client who Crohn's disease and has an ileostomy.
Answer:
A client receiving continuous enteral feeding through NG tube
Question:
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound.The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?Wear an N95 respirator mask, Wear sterile gloves, Wear clean gloves, Wear protective eyewear.
Answer:
Wear clean gloves.
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